Provider Demographics
NPI:1215485677
Name:IMPLANT ENDO INC
Entity type:Organization
Organization Name:IMPLANT ENDO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYUNG-SOO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-245-4564
Mailing Address - Street 1:505 N LAKE SHORE DR STE 215
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3678
Mailing Address - Country:US
Mailing Address - Phone:213-245-4564
Mailing Address - Fax:312-467-4684
Practice Address - Street 1:505 N LAKE SHORE DR STE 215
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3678
Practice Address - Country:US
Practice Address - Phone:312-467-3771
Practice Address - Fax:312-467-4684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024334261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental